PHARMACIES

Is every pharmacy included in every PDP?

No, each PDP establishes its own network of pharmacies.  The PDPs generally include many pharmacies in their networks.  A dual eligible will be able to receive prescription medication only from a pharmacy that is participating in that PDP’s network. This is also true for individuals who live in ICFs/MR; these individuals will need to ensure that the long term care pharmacy’s facility is a network pharmacy. When dual eligibles receive their auto-assignment letter from CMS, the dual eligible can find out whether their pharmacy is included in their auto-assigned PDP’s network by asking their pharmacist if the pharmacy is participating in their PDP, by calling 1-800-MEDICARE (1-800-633-4227); or by checking the website, www.medicare.gov.

What if a dual eligible is away from home and needs to fill a prescription?

Each PDP must have provisions for how to deal with the occasional or unavoidable need to use an out-of-network pharmacy.  These protections cannot be used for routine out-of-network access.